How can patients accept cash-based practices?

A primary care physician named Ashley Maltz recently discussed advantages and disadvantages of a cash-based practice. I appreciate her evenhanded tone: She prefers this model yet expressed concern for patients who can’t use it. In the comments section, several physicians extolled the virtues of cash-pay, but patients were mixed. It’s attractive for those who can afford it, while it worries, and maybe angers, those who can’t.

I enjoy the personal and patient benefits of a mostly cash-pay psychiatric practice (I also see some patients under Medicare). I like running my own small business, keeping clinically useful paper charts as opposed to a ponderous EHR, and protecting my patients’ privacy. Billing is simple enough that I do it myself. There is also an argument for keeping the relationship dyadic, i.e., 2-person, in psychotherapy. Third-party payers can complicate the therapeutic relationship in a domain where clarity is paramount. Most of my private practice colleagues likewise avoid insurance panels. It’s become the norm in my field.

Yet we’re all painfully aware that most of the seriously mentally ill can’t come to our offices. They are relegated to county clinics, training settings, and to the rare private practitioner who still accepts public insurance. Like Dr. Maltz, I’m saddened that,

those on Medicaid or disability programs cannot be seen for cash by medical providers for medical care. Most of these people do not have the financial means to seek alternative types of care. Thus, they are seen in large community clinics with overworked providers and limited resources.

Some critics of cash-based psychiatric practice exaggerate, painting a picture of high-society shrinks getting rich off the worried well. They point to real or imagined $400 per hour psychiatrists calming the Silicon Valley nouveau riche. Others like Allen Frances M.D. provide a more balanced critique, noting that individual psychiatrists gravitate toward more functional patients, but that we are only a small part of a very large puzzle. It appears that as a society we prefer not to pay for treatment of the seriously disturbed, but only for the jails and prisons they occupy after committing minor property and lifestyle crimes due to their condition.

Our situation in psychiatry is a harbinger for primary care. There’s no denying the advantages of cash-based practice; it serves both doctors and patients very well. Yet cash-based primary care practices, like psychiatric practices, exclude many patients who can’t afford them. They can’t comprehensively serve the primary care or psychiatric needs of a population. Even more obviously, almost no one can pay out of pocket for more elaborate medical care, such as major surgery or a lengthy ICU stay.

There’s a basic tension between health care as a private transaction and health care as a public good. Regarding the former, we can show our compassion by offering some free or low-fee care, or by treating some publicly insured patients under Medicare or Medicaid. This way we avoid elitism and do our part for the less fortunate. However, we must recognize that no matter how charitable we are as individual physicians, many more are in need of our services than our charity can accommodate. The private transaction model of medical care cannot save sick people from dying in the street. Universal access to health services is needed.

While taxpayer-funded Medicare and Medicaid cover many patients who cannot otherwise afford care, our current backstop is EMTALA, the 1986 federal law requiring hospital emergency departments to evaluate and treat emergencies regardless of ability to pay. According to the Centers for Medicare & Medicaid Services, 55 percent of U.S. emergency care now goes uncompensated, costing hospital systems tens of billions annually. Much of this cost is shifted to paying patients, inflating medical bills for everyone else. One way or another, society (i.e., we) pay to keep our fellow Americans alive and relatively well. It would be far more economical, not to mention humane, to offer universal access earlier, before health problems progress to emergencies — just as it would be to treat the seriously mentally ill before they need to be imprisoned.

It’s no surprise that many patients who are otherwise sympathetic to the plight of demoralized, burned out doctors draw the line at a cash-based care model that excludes them. In order to ally with these patients, those of us with cash-based practices should at minimum acknowledge the need for a two-tier model, public and private. Better yet, we need to think hard about who provides services in the universal-access public tier. Should this be all of us at some point in our careers, i.e., a type of “doctor draft” or public service requirement? Should these services be relegated to PAs and NPs? Or can we “let the market decide,” such that these services are provided by physicians who aren’t sharp, ambitious, or economically secure enough to hang a shingle — or for whatever reason prefer not to? These hard questions must be answered if we’re to be intellectually honest and admit that the physician’s role in society is more than entrepreneur.

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How can patients accept cash-based practices? 44 comments

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Dr. Drake Ramoray

Good article.

This is a well balanced piece written on the issue. I do think it discounts that third party payors accelerate health care inflation. Pharmaceutical companies couldn’t charge $800 for a bottle of insulin if there weren’t insurance companies who paid for it. Lilly made over 8 billion dollars in sales on Lantus (glargine) that was developed over 15 years ago.

Price acceleration of course then leaves those without insurance (or crappy insurance) in a bind to receive modern treatment. This likely goes beyond the scope of this piece; however this happened on a national scale globally with the health care inflation that occurred following the initial passing of Medicare with the “usual and customary fees.” I contend to some effect that this continues today with Medicare Part D coverage and the current pharmaceutical/device maker environment.

In theory, if most people moved to a more cash based system for routine care and health insurance returned to a catastrophic coverage model then prices would come down (even more so as PA/NPs roles continue to expand thus increasing supply). What we are witnessing is the opposite with the consolidation of healthcare systems and then them using their monopolistic weight to increase prices which then further disincentivies seeing those without insurance or on Medicare/Medicaid.

That being said I don’t expect a more direct pay model to become the modus operandi on a wide scale any time soon for a number of reasons. Whether you consider health care a right or a public good (I don’t want to reopen this discussion) the pendulum continues towards more things being covered and patients wanting to pay less. The requirements for coverage from ACA. Lets also not discount the fact that between Medicare, Medicaid, and VA the government already funds some 66% of healthcare anyway. Who would get elected suggesting that the government pay more or cover less. In addition, advocates of a single payer system point out the administrative cost savings of moving to single payer (I personally doubt these would hold any longer (see the recent articles on here regarding government sponsored (MACRA)).

Within practices. Our group has largely moved the high red tape diagnoses (diabetes) to the NP/PAs in our group as opposed to specifically Medicare although with the recent MACRA changes our physicians are limiting Medicare too. I haven’t seen a direct referral from an MD in the Oncology group in about a year. They have hired an army of nurse practitioners and PAs. The MD does the initial visit and after that they run a sort of residency style clinic where they “supervise” the NP/PA much like attendings did for residents in training.

As for required charity care or other ideas associated with those who are developing a direct pay practice, this is likely to occur on multiple levels.

I think taking Medicaid or Medicare will be tied to physician licensure in the near future. See comments section in the kevin MD segment below.

I suspect that once direct pay/concierge medicine reaches a critical mass that it will become illegal. Hillarycare in one iteration actually banned the practice and I suspect that the ACP will declare it unethical in the relative near future.

Direct pay/concierge practices days are likely numbered in my opinion.

Keith Pochick

Very well said. I always enjoy your comments, even when I don’t wholeheartedly agree.

PW

“Hawaii is actually the closest to making Medicare a condition of state licensure:”

And guess what? There is a shortage of physicians in Hawai’i. Now, there are probably a multitude of reasons, but this won’t help.

vicnicholls

Thank you for the resources. Very much so.

Keith Pochick

I enjoyed the article.

Essentially, it is a philosophical discussion about whether one views health care as a commodity or a public service. Is medical care akin to having government run waste management or water treatment service to promote a healthy population, or is it a “you get what you pay for” service to be exchanged on the free market?

The truth is that it obviously has components of both. It just boils down to where one falls along the spectrum mentioned above. I think we would be incredibly naive to think that a system could be designed which provides all Americans equal access to, and quality of, healthcare. Even in Canada, the wealthy can go outside the system and pay more for more timely (although only questionably higher quality) care.

People who are wealthier will always have better food, better schools, better health, and better homes. We must be able to accept this as an enduring fact, regardless of how idealistic we may be. If the United States were to outlaw cash-only practices, the physicians and patients who desire it could always move. Remember that wealth is the strongest predictor of mobility.

Healthcare and medicine will continue to erode and become more and more “watered down” so long as those who provide it are enslaved by regulations, dwindling income, and bureaucracy. I, for one, applaud those exploring options which exist “outside the system.” Innovators, by definition, have to exist on the edges.

graybeard

“Innovators, by definition, have to exist on the edges.”

I love this. But I would add that sometiimes they exist ‘outside’ or ‘between’ as well.

And I cannot agree more that everyone involved in healthcare reforem, including voters, need to keep it in mind that it is both a public service and a commodity. Reform should be done with proper emphasis in respect to this fact, with big ticket issues like oncology, hospitalizations, public health services (including immunizations), and some expensive early detection tests like colonoscopies, etc being on the public services end of the spectrum. Office-based care, and even the doctor’s part of at least some hospital incidents left to the free market (outside of any third party involvement) on the commodity end, always with special assistance to those on the lowest end of income.

Thomas D Guastavino

I say if society is uncomfortable with cash based medical care then society has to fix the nightmare of what, especially government based, insurance has become, about to become the sheer night terror of quality based reimbursement.

Louise

I have one doctor (at MD Anderson Cancer Center) in my immediate family and 2 other doctors in my extended family. Cash only practices are just another form of the way medical care has been accessed for decades in America: the wealthier a person is, the better medical care access and treatment they can buy. American medical care: “Your money or your life.” Nothing new under the sun . . .

Thomas D Guastavino

Insurance based health care worked well until outsiders tried to “fix” it. Medicare worked well from the late 60s to the late 80s. The poor even got care because most physicians did provide some pro-bono care. The outsiders and politicians thought they knew better and now physicians are fed up and opting out of the entire insurance market.

Louise

But how on earth can the entire American medical care system now be “fixed” in a way that does not end up interfering with millions of people’s ability to access timely medical care? It just seems like it is such a completely mess. Due to doctors in my family, i am sympathetic with what medical profession is now dealing with. I believe these days docs are caught between rocks and hard places. But it is even worse for majority of patients (unless wealthy as Trump, Clinton, and majority of corrupt Congress!) It is very frightening for people – like me – who know in future my life literally will depend on if can get treatment, without bankrupting my family. Which i won’t do! I have 50/50 chance breast cancer will show up again. I don’t think many doctors realize how truly scary it is for patients with serious medical problems to think about future of medical care affordability and access. It’s like having a huge black could over the future. It figures in so many family decisions. My husband & I have to try to decide on things, like: our house (one of our major assets) needs siding. But do we take the $8000 – $9000 out of savings to reside the house, preserving its value, or not? What if that money is needed in a few years for medical care? Do we replace one of our cars with almost 200,000k miles on it (a 2005 Honda minivan) which is now having more and more mechanical issues – or not? Because we don’t know how much $$$ we’ll need for medical care in the future, especially if i have to deal with cancer again. We are only Middle class people – not rich.

Thomas D Guastavino

The first thing that needs to be done is to scrap every health reform measure of the past thirty years. Admit that the “bad doctor” theory of health reform was a mistake. Let doctors be, once again, doctors. Then decide if we want private or public funding. If private look at ways of increasing competition such as cross state line private insurance. Dedicate 100% of sin taxes to health care, where it should have gone in the first place. And PLEASE have real tort reform.
If public funding be honest as to what limitations exist and accept them. Realize that there will be rationing and that physicians will have to unionize and malpractice will be handled in an entirely different way. The amount of health care that the public receives will depend entirely on how much society is willing to spend.
No system is perfect but we can do better because the current idea that high quality, low cost immediate access to all aspects of health care for 100% of the population can be beaten out of physicians is not working.

Louise

Republican Legislature in Texas years ago dealt with medical lawsuit restrictions. Did nothing to bring down price of medical care in TX; but it did reduce malpractice insurance rates. What i’ve heard about allowing insurance to be sold across state lines is the insurance corporations will do exactly what banks did: headquarter in a few states with most benefits to insurance companies and most restrictions to policyholders. Well, i don’t come from family where people live long time (my husband does). I’m in my early 70s; will be pleasantly surprised if i live another decade. But i sure do worry about what kind of country it will be when my only grandchild is grown; she’s 9. Will she get medical care if she’s not rich?

Thomas D Guastavino

So, what would you do? Ive heard the complaints and the concerns but no real solutions.

Louise

Husband is a chemical engineer. Over course of his career, we were transferred to foreign countries with so-called “socialized medicine.” Canada, Germany, England. I think Medicare should be opened up for people to buy into. Richer people can continue to pay cash for their medical care and and should get a discount – not be charged inflated price because they are not insured. Also, the master charge list of all prices for all common procedures and tests should be posted at every hospital website and for all private doctor practices. People with and without insurance should be able to freely shop around with no false restrictions from insurance companies. I also strongly believe Medicare should be able to negotiate drug prices, just like the VA can. I don’t believe there is any “perfect system” for providing medical care access to every person. There will always be some people who benefit more than others, and some less than others. But i think it is sort of shameful that a country as wealthy as America still has so many people who suffer and/or go bankrupt merely because they happen to be seriously ill or get seriously injured, aren’t insured – have no TIMELY access to good quality care. You have to remember i live in Texas, the state with highest number of Uninsured people. Medical care access for poor/uninsured is very poor here! Also,I hear a lot about cancer patients spending down to their last dime on medical care, often savings they’ve acquired over a lifetime of work from my daughter who works at MD Anderson. It’s pathetic America spends so much more $$$ than any other country but with not the results to show for all the money spent. I’m sure i don’t have all the answers or even the best answers. I owned/operated a successful small business for almost twenty years. But the medical care business involves people living, dying or going broke. I would say only other profession where a single person or only a few people literally control if people live or die are commercial airline pilots – also, now that i think about it, maybe air traffic controllers (one of my brother-in-laws is an air traffic controller.) Flying seems safer these days than medical care.

Thomas D Guastavino

You said you lived overseas but you did not comment on how socialized medicine worked in those countries. Master lists will not help because charges are set by medicare and very similar for a given procedure. I have no problem with “buying” into Medicare except that is another step toward single payer and really does not effect the cost issue. Same with medicare negotiating with drug companies. Go to far and you stop the innovation that got the drugs in the first place. The bulk of your post is, once again, a rant and your last line says it all. You consider access to health care an entitlement. You really don’t trust the medical profession and it appears that you do believe that physicians need to be controlled. You are, of course, entitled to your opinion but don’t be surprised when access continues to deteriorate.

Louise

I do think access to medical care is a right. I am not a “survival-of-the-fittest” believer. I am Christian; my religious values don’t allow me to think people should be allowed to die and/or go bankrupt if they aren’t rich enough to access timely medical help. No, i DO NOT trust medical profession any longer! Because for 3 YEARS i was told by an imaging center connected to a well-thought of private hospital as i was being followed for abnormal mammogram it was “a cyst,” and the dilated duct “nothing to worry about.” Then when i started having off again-on again nipple discharge, went to Breast Center associated with medical school (it was NOT University of Texas-MD Anderson), was told by 2nd opinion radiologist, “We see women here frequently with discharge that is NOT associated with breast cancer. Mrs X, i see NOTHING for us to WORRY ABOUT.” This 2nd opinion was AFTER my primary care doc when i went to him first about discharge said in his opinion i HAD DUCTAL breast cancer. He told me to get it checked out ASAP. My family doctor is Board Certified Family Practice physician whose OWN WIFE had breast cancer when she was in her late fifties age. So my PC doc is very familiar with breast cancer as well as being in practice for years – he’s in his early sixties – and having women become breast cancer patients! He sent me to 2nd opinion with his written potential diagnosis of ductal breast cancer. Plus, my grandmother died of ductal breast cancer; i had cyst removed in my twenties; had adenoma removed in my thirties – was told at that time i was at higher risk for breast cancer. When i ended up at MD Anderson Cancer Center, and their radiologist went back and looked at all my years of previous mammograms, the cancer in the breast ducts was viewable way back in 2011! But MISSED by Imaging Center radiologists for THREE frigging years! By time i had mastectomy at MDA in August of 2014, the cancer cells were EXTENSIVE. It was grade 2 cells, including one particular type of cancer cell considered a very nasty cancer! The cancer extended very far back toward my chest wall. I have 50/50 chance of reoccurrence. Supposedly it was not in lymph nodes. But i had so many nodes removed “to be on safe side” to check for cancer in them, i now have a lot of lymphodema in chest wall and under arm. I can’t wear a bra for more than a short time without a LOT of discomfort! My team of cancer doctors at MDA, of course, never would say much about how it was i was misdiagnosed for 3+ years by hospital-associated Imaging Center. Then was also grossly misdiagnosed by the SECOND opinion radiologist even after going there with my primary care doctor’s opinion it was ductal cancer! But a lot of the nurses i’ve met during past 2 years when i tell my story say they don’t understand why radiologist-2nd opinion didn’t order a biopsy, especially considering my history and the discharge! One Nurse remarked to me when i was at MDA at end of January this year for 6 months checkup, “Wow, i wonder what kind of rotten luck you had to have gotten a blown diagnosis from your second opinion? It is terrible this happened to you!” Trust Nurses to tell it like it is! Doctors just circle the wagons. You bet your bippy I’m BITTER and cynical! So, NO I DON’T TRUST MEDICAL CARE anymore! Plus i have 2 relatives and 2 friends who have died during past 8 years solely due to being MISDIAGNOSED from the beginning of their symptoms! I was not one little bit surprised that IOM has been saying how much bad medical care there is out there. And then very highly respected Johns Hopkins verified it this year!! As for when we lived in Canada (two plus years), Germany (almost 2 years) and England (4 years), in all of those countries at the time we were living there, medical care was excellent. England was most interesting. Because for 18 months we lived in London, we had private insurance. Went to rather snobby Harley Street doctor. But when we moved to chemical plant site (which was being expanded) up in industrial (poorer) NE England, none of the doctors reasonably close to where we lived took private insurance patients. (British doctors must take NHS patients, but can refuse private insurance patients.) So in NE England we had medical care under NHS doctors. Guess where we had better medical care? Yes, from NHS doctors in NE England. My daughter got thrown off ride at a traveling fair. (These traveling fairs run by Gypsies go around England during summertime.) Daughter had ruptured spleen, broke collarbone. Had emergency surgery EXCELLENT most compassionate medical care at hospital in York. Compared to when we returned to USA and a few years later my son broke his arm above elbow. A few minutes after we got to ER we were besieged with people demanding our insurance info. Then there was hold-up when they had trouble verifying it! My son was made to wait, lying there IN PAIN for almost an hour while the hospital dicked around trying to verify our specific insurance benefits. He was 12 years old! Our last foreign assignment was from end of 1970s into the 1980s to Great Britain. We still have some good British friends we made while living there. We’ve gone back once to visit and they made their first trip to America to see us. We still have one couple we’ve stayed friends with in Toronto. In England their medical system is going down, but worse in some parts of country and better in other parts. O Our friends in Toronto tell us they have excellent medical care access and quality of care. Plus MUCH cheaper access to drugs. When we lived in Canada years ago the Canadians were looking for chemical engineers. We had opportunity to stay there, eventually become Canadian citizens. I often think it is one of the worst decisions of our lives my husband & I didn’t do it. We didn’t because we are both native Houstonians and wanted to be able to come back home where majority of our families are. Our Canadian friends who live in Toronto (retired from Canadian arm of Exxon) are always telling us how grateful they are they’ll never need to worry about going bankrupt due to medical problems; they don’t worry they can afford their medications. Our Canadian friends say they only have to wait for awhile for non-life threatening medical problems, but never anything life-threatening. Our Canadian friends tell us if a Province is run by a Right-leaning or Left-leaning Gov makes a lot of difference in quality and access to medical care in Canada! The Provinces with the Right Wingers seem to have worse medical care!

Thomas D Guastavino

I am sorry for the experience you had. So you want socialized medicine and you are bitter and no longer trust the medical profession. Fair enough. May we have a trade union with full collective bargaining rights ?

PW

Doctors very much realize how scary it is. Doctors and their families get sick too. The costs are getting to be untenable for almost everyone except the Trumps, Clintons, Kardashians and the like.

NewMexicoRam

This author is forgetting something: high deductible health plans.
Mine is $5000 per year. I’d more than willingly pay a slightly reduced fee per service or an annual membership fee to see my doctor at just about any time and quickly.
And that’s the sort of practice I will be starting in 2 years. Either sign up for a reasonable annual membership fee, or pay fee for service, with the fees set just below what the big box clinics are charging.
I mean, as high deductible plans proliferate, more people will be looking at the service they get for the cost involved.
I plan on fitting into that niche.

Markus

Different specialties have different perspectives. In oncology we work with the patients’ insurance out of self-interest. Our typical patient would have symptoms with an imaging workup that cost $5,000 followed by a surgery for $30,000 and then chemotherapy costing another $30,000. All of these bills pile up in 6-8 months, and I am certainly aware that the tab was higher for many. Few people have that kind of liquidity, and medical bills are important in about 55% of personal bankruptcies. Thus people rely on insurance. However, insurance carriers do not exactly spit out cash easily and readily. Meeting the carriers’ requirement for a clean bill means that there is a great risk of real delays unless the bill is submitted by someone who is pretty savvy about the insurance world. It is hard to imagine cash out of pocket practices for many big ticket fields.

EricMD

Your field would fall under catastrophic. You are right a cash based practice would not really work here. But if most other services in medicine other than catastrophic issues cash there would be plenty of money left over for catastrophic insurance based issues.

It’s like care insurance. They pay you if you get in an accident but not if you need new tires and brakes.

Dr. Drake Ramoray

Ty Joe. And to all that have reaponded. I agree on the blip of the AMA, although it is looking like the move will be to infrequent testing instead of or even in addition to a ten year high stakes test. It would appear they will just boil the water more slowly, and there is no evidence that it will be less expensive or onerous as of yet.

Also note in the provided link that it would appear you have to “perform well on these shorter assessments to test out of the current 10 year assessments every ten years”

Gotcha.
The ACP hasn’t ever helped me, so instead I’m going to help both myself and my patients.

Thomas D Guastavino

We should not take want to “stick it to the poor” What you said about the politics of all all of this is very true but very sad. The fact that some physicians have been forced to restrict their practices to cash only, along with early retirement and avoidance of difficult patients, was entirely predictable and understandable but not something to celebrate.

EricMD

I like this statement Guastavino.

It’s not about sticking it to anyone. It protecting one from the mess we are in.

PW

CONSIDERING the PCMH costs at least $100K to start and maintain, most smaller practices couldn’t even CONSIDER it. Not only that, smaller practices have been shown to be very effective in similar measures as the PCMH. I can’t put the link up here, but it’s in AAFP News Now.

B. Renzulli, MD

I am actively transitioning to a direct pay practice and have not turned away any patients who wanted to stay with me but couldn’t afford the monthly fee. I still ask them to pay something, but we adjust it to their means. I am also continuing to accept one insurance – Medicaid – as this serves our most indigent population. It is not an either/or proposition in my mind. In all things, I simply try to meet my patients where they are, including financially.

PW

And this is how it should work.

querywoman

Did you get your education a buy now, pay later plan?
I have no problem where I live finding doctors to take my Medicare, and I’m in a huge area.
Psychiatry has always been a problem on Medicare. Doesn’t it just reimburse 50 percent of Medicare agreed rates?
I mostly consider the public and semi-public clinics better than private psychiatrists around here.

Patient Kit

Psychiatry being a dominantly cash-only field of medicine is a major reason why I’m against primary care and various medical specialists moving to cash-only models. Way too many Americans who need it do not have access to psychiatric care because so many psychiatrists do not accept insurance. I don’t want to see the same happen in other areas of medical care. And that is exactly what I think would happen if most doctors switched to direct pay models. They’d be as accessible as psychiatrists to many — or most – Americans.

querywoman

It’s still a very small percentage of docs who are cash only. Yes, psychiatrists have done it for years.
Psychiatrists are usually different from most other docs because they usually don’t do blood work. They are like lawyers, in that they bill mostly for the time. They also don’t make as much as other doctors.
In the past, like in the 1980s when no one else took insurance assignment, many local psychiatrists would.
I’m neither praising them or condemning them, just pointing out their differences.
Even if lots of existing docs go direct pay, tons of younger docs graduate all they time and they tend to need the insurance dollars at least in the first ten years.
So I’m not worried about it.

PW

In the early 20th century when the poor and middle class couldn’t afford doctors, the doctors would adjust prices or do pro bono care. See Dr. Renzulli’s post above.

Patient Kit

In this day and age, I don’t think the general public trusts that most doctors would do that today. I just don’t think that kind of trust is there. Another issue is, without universal healthcare, how do doctors choose who they will treat pro bono or for a deeply discounted fee? And what happens to the unchosen?

PW

Well, Dr Renzulli is doing it. I have a patient whose worker’s comp stopped paying. I have agreed to continue treating her for a very small fee. So, it can be done. Heck many docs in our community and others have volunteered for free clinics.
I think we need to consider multiple options for healthcare in the future.

Patient Kit

And I think it’s great that Dr Renzulli and other doctors are doing it. But, realistically, how many private practice doctors who convert to cash-only do you think will voluntarily accept Medicaid (or Medicare or a sliding scale fee) like Dr Renzulli? The “rely-on-the-kindness-of-stranger-doctors” plan sounds very unreliable to me.

PW

Note:

I said multiple options. This could mean “relying on the kindness of strange politicians/government” too.

OP here. Thanks to everyone for your thoughts on this complex issue. Some of you introduced other angles: “Drake” on the cost inflation introduced by 3rd party payers of any type; the accurate observation by Keith Pochick that the wealthy will always enjoy better housing, food, and health care; the fact that an oncologist like Markus has to rely on insured patients; Louise’s points about price transparency and the need for Medicare to negotiate drug prices. I also agree with Dr. Guastavino’s call for tort reform, and an honest admission of the limitations of public funding. Yes, there will be — is — rationing in any such system, just as there is by private insurers. And, absolutely, we’ve been hog-tied by the “bad doctor” theory of health reform. I endorse Dr. Renzulli’s compromise, which mirrors my own.

A two-tier model is not ideal. It underscores the haves vs have-nots, and it’s more complex/bureaucratic than any unitary model. However, in a society where health care is both a public good and a marketed service, it’s the only way to accommodate both.

Will cash-based practice be outlawed if it gets popular? Obviously I hope not, it’s how I make my living. Maybe we can avoid this possibility by shedding our passivity and working actively, and loudly, to solve the public-good side of the equation. A concession that all MDs work in the public sector for a couple years — a public service requirement — may be a reasonable price to pay for the freedom to be unfettered entrepreneurs for the balance of our careers. (I myself worked in a public mental health clinic for two or three years early on.) Unless we propose a workable alternative, this one or another, the public and its elected officials will make sure the public-good side of the equation isn’t neglected, whether we doctors like it or not. We need a better solution then retiring early, holding mini-strikes, or moving abroad.

Patient Kit

I’m all for doctors working on solving the “public good side of the equation” and finding a way that works for both doctors and patients. But wouldn’t your proposal that all doctors work in a public health clinic for 2 or 3 years before moving on to being an “unfettered entrepreneur” for most of their career mean that we “have-nots” would mostly only see very young less experienced doctors and that there would be no hope of continuity or doctor-patient relationships because our doctors would always be a year or so away from leaving? What about all doctors treating an agreed-upon percentage of us “have-nots” for their entire career? Would spreading the burden of treating us among all doctors make the burden manageable for most doctors?

There are pros and cons to any of these ideas, and I’m not wedded to the one I came up with. However, your proposal is close to the status quo that many doctors are now rejecting. Billing 3rd parties requires back-office employees or outsourcing, increasing overhead to the point where direct-pay isn’t sustainable. It’s inherently more expensive to treat in private-practice settings versus more utilitarian public settings, so government would either pay private-practice rates for the have-nots (won’t happen), or doctors would lose money on these patients (as we do now). And then there’s the philosophical/political question: should the quality, timeliness, and comfort of medical care be the same whether a patient can pay or not? Or should we instead aim to assure a basic level of care for everyone, and allow those with means to buy more/better? No doubt there’s widely varying, and strongly held, answers to this question.

Patient Kit

I don’t pretend to have any easy perfect answers either. I’m here to listen to doctor’s perspectives and to share my own perspective as a patient who now has personal experience with being covered by private insurance, Medicaid, an ACA plan and being uninsured at the time of a cancer dx. In my experience, being uninsured is, by far, the worst status in this country. I’m about 5 years away from Medicare. Maybe if we brainstorm together enough, we’lll come up with something that can work for all of us. So many other countries have managed it, one way or the other. I believe the US can too.

But your suggestion of doctors doing 2-3 years at a public clinic prior to launching their real career path sounds too much like all poor people only seeing residents. That wasn’t my experience even while I was covered by Medicaid. Sure, residents were involved in my care and I was happy to be part of their education. But my main doctors, both GYN oncologist and primary care, were experienced attendings. I would not have been comfortable only seeing inexperienced residents.

vicnicholls

Thank you.

Patient Kit

Nice. Your contempt for the poor and desire to “stick it to the poor” for having the audacity to want access to medical care is despicable. I hope you are not a doctor.

graybeard

One of the things pushing docs out of private practice, besides the student loan issue, is the high cost of insurance for the self-employed. Shaving off office visits and minor labs/imaging from the involvement with insurance would help control the cost of insurance and help self-employed doctors. And other self-employed. The high cost of health insurance is killing the dream of being self-employed.

Suzi Q 38

Today I paid my acupuncture doctor in cash because my insurance company does not pay for acupuncture.
I held out two bills (a $50.00 bill and a $100.00 bill). I asked him which one do I pay him with.
I was sick and tired of the government and the paperwork. I felt that he should get the full amount of money I pay, and I could also get a discount if I paid cash.

I did the same with my PCP the last time I saw him. I was curious as to which bill the doctors would choose.
I know it sounds strange, but some of us who are employed do not mind paying for services. I pay my hairstylist, the person who painted our house, etc.